Why do alcoholics bleed to death?
In order to explain this, I'm gonna have to get a little pathophysiological, as I promised in an earlier post.
Most chronic alcoholics die shitting or vomiting blood. It seems like a weird connection, especially if (like most people in a non-medical arena) you're not totally clear on what the liver does exactly. Something to do with poisons, right?
Well, yeah, but not just poison. A lot of things come into your body through your mouth, and you can feel free to insert your own dick jokes here, in much the same way that you insert dicks into your mouth. That shit ranges from "inadvisable and kind of sweaty-tasting" to "straight-up block of pesticides" and your stomach and intestines give no shits about this. If you swallow a mouthful of jizz, as far as your stomach is concerned, you just had a teaspoon or two of protein supplement, and your pancreas will happily bathe it in flesh-dissolving enzymes so your intestinal bacteria can chew it up and shit it all over the absorptive walls of your intestines. Directly outside of those gut walls, blood vessels happily pump away the acid-bathed, pancreas-liquefied, bacteria-digested jizz protein for your body to make into more of itself.
Hold the fucking phone, you say. That jizz was probably nontoxic, but what about the other nasty things we eat every day without realizing it? The 2.5 spiders you swallow in your sleep every night-- where does their venom go? That waxy shit on the outside of cucumbers that tastes like Raid? The shampoo you got in your mouth last time you showered? (I know I'm not the only person who has this problem.)
And worse, even if you assume that the intestinal walls have some pretty strong filtration powers to separate the shit from the food, what happens when you get horrific diarrhea and your insides get raw? What if you eat too much corn and you scrape up your gut? What if you have hemorrhoids and your body is constantly insisting that you have to squeeze fist-sized turds directly over the open wound that your asshole has become? Oh my god, you are going to have shit blood poisoning and die.
So here's the trick: your body has two separate blood-circulating systems. One of them is systemic, and full of delicious clean blood with lots of carefully sterilized proteins and freely-available sugars floating happily through it, ready to feed your heart and brain and other assorted bits without subjecting them to anything gross at all. The other is intestinal, and it's a fucking junkyard of sloppy proteins that still look a little like the sperm you chugged to begin with, plus all the other poisonous chemicals you've splashed in your mouth recently, plus all the perfectly natural nitrogen waste that comes with living and is incredibly disruptive to brain activity, plus any traces of shit that are scraping their way into your bulging assgrapes. Fortunately, this complete wasteland of trash is outfitted with a couple of critical defenses.
First, you have tons of lymphatic drainage in your intestines. I'll cover the lymph system later sometime, but it's like an alternate circulatory system, a set of loose-mouthed leaky veins that pick up extra water and trash and scour it with macrophages that live in the nodes.
Second, the intestinal system is on a closed circuit that only returns to the rest of the body through, you guessed it, the liver. Inside the liver, the jizz proteins are reduced and converted to more usable proteins; chemicals are scrubbed and pumped back into the shit chute for dumping. The hepatic portal (literally the "liver door") refers to the tiny straw-like filters through which all your blood has to squeeze on its way in and out of the intestinal circuit. All of your blood goes through here, and the pressure gets pretty high.
Alcohol and other liver toxins scar up these tubes and make them stiff and tight, forcing your blood to squeeze through smaller and smaller spaces. Healthy liver tubes are flexible and have a little bit of give; scarred tubes are about as flexible as particleboard. Cirrhosis-- liver scarring-- results in portal hypertension, or excessive pressure on either side of the liver-door. On the systemic side of the door, backed-up blood bloats into hemorrhoids in the esophagus, which eventually burst and bleed, often catastrophically. On the intestinal side, so much blood builds up that the extra fluid is forced to ooze out into the abdominal cavity, forming that stretched-out, water-filled liver-failure belly you see in liver pts and chronic alcoholics. This is in addition to similar ready-to-pop situations in your intestines, which can blow out at any time.
Adding insult to injury, the liver takes all these proteins and food particles and makes all your blood clotting factors out of them. A failing liver, or one continually taxed by alcohol or tylenol/paracetamol, is too busy struggling to filter and repair to be effective at making clotting factors. And, being in a prime position to monitor your nutrition status, your liver has control of your body's access to its food stores-- control that's mediated largely through proteins.
The thing about proteins is that they're basically specialized wrenches, low-tech thing-grabbers designed to grab the thing they're made to grab and move it however it needs to be moved. They CAN be broken down for energy, but they're terrible energy sources, and the more protein your body has, the more wrenches it can build. And what builds your wrenches? Yeah, it's totally your liver.
And while you probably know about platelets, and with a little brain-poking you can probably figure out that those are blood cells and come from inside your bones, you should also know that platelets don't do much more than grab broken areas and then group-hug. They really aren't a fix for a torn blood vessel. Fortunately, once they're group-hugging your wound, they can secrete chemicals that activate the wrenches around them-- things like fibrin, which helps you heal and build scar tissue, and which forms the bulk of a dry scab.
Platelets by themselves don't last all that long and can't make a decent scab. But if they have the tools, they can build huge structures to protect your blood from wandering off. And what are these hammers and wrenches?
Proteins.
And what makes your proteins?
Yeah, you get the idea.
So if you start bleeding and your liver is shot to shit, good luck. Your body is going to forget how to clot very quickly. And that is why alcoholics die bleeding from the throat.
Wednesday, July 15, 2015
Week 3 Shift 2
After six days off to hang out with my middle sister, the one who works as a CNA, and get my social life on (it's very sad and lame and involves babysitting and eating teriyaki), I went back to work this morning for a stretch of three days.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Week 3 Shift 1
I totally expected to get Crowbarrens back today, but I guess some other poor sucker got that assignment. I heard him yelling as soon as I got on the unit—I CAN’T BREEEEEATHE—but I ended up at the other end of the hall from him.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
Tuesday, July 14, 2015
Week 2 Shift 3
Today I worked at my other facility, where I used to be a full-time night-shift ICU RN and am now working per diem shifts on days. This hospital and I have some bad blood because their method of handling conflict and "incident reports" involves a lot of stewing and poor communication. Like I might be a bitch to that CNA I chewed out, but by fucking god I talked to her about it, and after this I plan to discuss it again after a few more shifts with her (to see if our initial agreements smooth things over) and if necessary seek mediation from a higher-up. ICUs have too much shit going on to let drama grout up the corners.
This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.
Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.
Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.
One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.
Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.
Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”
The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside).
Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies.
While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.
The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.
"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."
I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.
Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.
I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.
Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.
Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.
The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.
A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.
This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.
Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.
Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.
This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.
Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.
Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.
One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.
Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.
Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”
The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside).
Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies.
While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.
The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.
"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."
I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.
Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.
I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.
Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.
Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.
The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.
A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.
This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.
Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.
Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.
Week 2 Shift 2
Every morning at my main facility we all cluster around the front station, receive our assignments, collect our walkie-talkies, and get a quick summary of the daily shift news. Yesterday’s morning started out very strangely for me, because I was unusually late and clocked in at 0645 exactly, when group report starts. This meant that by the time I made it to the front desk, everyone else already knew who I’d be taking care of, and they all watched me approach with this blend of pity and relief that told me right away what was about to happen.
I was getting an albatross.
I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.
Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.
Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.
I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.
Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.
What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.
He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:
--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.
--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.
--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.
Lucky me.
So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.
HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.
I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.
My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.
After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?
At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.
She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."
I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.
Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever.
To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.
The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.
So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.
CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.
This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.
It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.
Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.
I was getting an albatross.
I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.
Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.
Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.
I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.
Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.
What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.
He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:
--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.
--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.
--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.
Lucky me.
So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.
HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.
I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.
My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.
After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?
At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.
She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."
I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.
Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever.
To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.
The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.
So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.
CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.
This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.
It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.
Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.
Sunday, July 12, 2015
Week 2 Shift 1
By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
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